To estimate a national perinatal mortality rate (PNMR) and to identify the major causes of perinatal mortality and related avoidable factors, missed opportunities and substandard care in South Africa.
All Provinces in South Africa gave input, where possible, into the PNMR in their particular Provinces. Furthermore, 27 state hospitals throughout South Africa representing metropolitan areas, cities and towns, and rural areas were the sentinel sites for the documentation of the causes of perinatal death and the avoidable factors associated with the deaths.
The provincial Health Information Sections and the Maternal, Child and Women’s Health units of the provinces presented their available data. Users of the Perinatal Problem Identification Program (PPIP) amalgamated their data to provide descriptive data on the causes of perinatal death and the avoidable factors, missed opportunities and substandard care in South Africa. The PPIP users were the sentinel sites. The PPIP sentinel sites were grouped into metropolitan, city and town, and rural areas. The metropolitan grouping reflects urban areas and a fully functioning tiered health care system with ready access to tertiary care. The city and town grouping reflects functioning primary and secondary levels of care, with limited access to tertiary care, and the rural grouping reflects primary care, with less accessibility to secondary and tertiary care.
Most of the provinces did not have effectively functioning data collection systems at the time of the workshop and were unable to provide accurate data for their whole province regarding births and perinatal deaths within state institutions. However, accurate data was available for Gauteng and the Western Cape. The PNMR for Gauteng was reported as being 32.1/1000 births and for Western Cape reported as 18.4/1000 births.
The delegates at the workshop agreed to a minimal data set and the perinatal care indices to be used to describe perinatal care. These will be discussed with the National Health Information Systems of South Africa for incorporation into the national minimum data collection set.
At the 27 PPIP sentinel sites a total of 4 155 perinatal deaths with a birth weight of 1000 g or more were reported from 123 508 births. The perinatal mortality rates for the metropolitan, city and town, and rural groupings were 30.0, 39.4 and 30.9/1000 births respectively. The neonatal death rate was highest in the city and town groups (14.8/1000 live births) followed by the rural group (12.1/1000 live births) and metropolitan group (7.6/1000 live births). The low birth weight rate was highest in the metropolitan group (18.4%), followed by the city and town group (17.0%) and the rural group (12.5%).
In all groups the primary obstetric cause of intrauterine death was unexplained in a significant proportion of cases. The most common primary cause of perinatal death in the rural group was intrapartum asphyxia and birth trauma (7.13/1000 births) followed by spontaneous preterm delivery (4.88/1000 births). The most common primary cause of death in the city and town group was spontaneous preterm delivery (6.07/1000 births) followed by intrapartum asphyxia and birth trauma (5.27/1000 births). The metropolitan group’s most common primary causes were antepartum haemorrhage (7.08/1000 births) and complications of hypertension in pregnancy (4.31/1000 births). Complications of prematurity and hypoxia were the most common final neonatal causes of death in all groups.
The presence or absence of avoidable factors was documented in 2 733 cases of perinatal death. Patient related avoidable factors were reported to be present in 35.9% of perinatal deaths, followed by health worker related (29.1%) and administrative (7.4%) avoidable factors. There was insufficient information to assess avoidable factors in 5.4% of cases. The most common patient related avoidable factors was no antenatal care, late initiation of antenatal care or infrequent attendance at antenatal clinic (present in 539 cases – 20%of all cases); delays in seeking medical attention during labour (150 occasions – 5% of all cases); and an inappropriate response by pregnant women to reduced fetal movements (133 occasions – 5% of all cases). The most common health worker related avoidable factors were inappropriate responses by health workers to problems identified during antenatal care (226 occasions – 10% of cases of perinatal deaths whose mothers attended antenatal care); problems of monitoring the fetus during labour (172 occasions – denominator for women in labour with a live baby not available); and delays by health workers in referring patients or calling for assistance (99 occasions – 4% of all cases). Lack of transport was the most common administrative factor recorded specifically in 72 occasions but large proportion of patients’ delays in seeking medical help during labour might have been due to transport problems.
The survey demonstrated some deficiencies in the data collection system. To improve the process of achieving a comprehensive perinatal care survey, a minimal data set for each Province needs to be implemented. To improve the quality of data on the causes of perinatal deaths and avoidable factors data more PPIP sentinel sites need to be established.
However, the current data is sufficient to state that the PNMR in South Africa is probably in the order of 40/1000 births, and some readily remedial problems have been identified. These are in the structure of antenatal care, management of labour, resuscitation of the asphyxiated neonate and care of the premature neonate. Focusing attention on these readily remedial priority problems, by ensuring that equipment, protocols and trained health workers are always available and by specifically introducing kangaroo mother care for the care of the premature infants, makes the reduction of perinatal mortality in South Africa feasible and inexpensive.
1. Adopt the proposed minimal data set and tool
2. Establish the process for collection of the minimum data set in each province
3. Establish more PPIP sentinel sites
4. Ensure each site conducting births has the necessary equipment and protocols and that the staff are appropriately trained to manage labour and are especially trained in the use of the partogram
5. Ensure each site conducting births has the necessary equipment and protocols and appropriately trained staff to manage asphyxiated neonates
6. Ensure each site caring for premature infants has the necessary equipment and protocols and that the staff are appropriately trained in kangaroo mother care
7. Ensure each site performing antenatal care has protocols in place for where to and when to refer patients and the staff are appropriately trained therein
8. Move to a system where the time and point at which the woman confirms she is pregnant also becomes the woman’s first antenatal visit where she can be classified according to risk and where her further antenatal care is specifically planned
Prof RC Pattinson
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